MEDICARE: DR. MALLORY CHRISTINE MACRAE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OR 3408ATI	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558659326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALLORY CHRISTINE MACRAE O.D.

Provider Business Mailing Address
First Line	:	4350 CHERRY AVE NE
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4855
Country	:	US
Telephone Number	:	503-393-6060
Fax Number	:	503-393-5096

Provider Business Practice Location Address
First Line	:	4350 CHERRY AVE NE
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-4855
Country	:	US
Telephone Number	:	503-393-6060
Fax Number	:	503-393-5096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2011
Last Update Date	:	08/19/2011

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